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OHR.HITS@montgomerycountymd.gov

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    • 1 Retiree Signature

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Dear MCG Retiree:

The 2021 Retiree Health & Life Insurance Election Form is now electronic; making it easier for you to submit your enrollment elections online without requiring the need to complete paper forms or return them to OHR manually. TIP: Opening in Chrome as web-browser is the best user experience.

To complete your 2021 Retiree Health & Life Insurance Election form, please read the message below, check the box that you are willing to complete a digital version of the election form and proceed to complete your form online.

Enrollment submissions must be received by the 10th of the month for changes to become effective on the 1st of the following month.

Enrollment in Medicare Parts A and B is required for all retirees and covered dependents when they become entitled to Medicare. Medicare entitlement occurs for most people the month they turn age 65. However, there are other reasons that you or your covered dependent can become entitled to Medicare earlier than age 65, such as Social Security Disability, End-Stage Renal Disease, etc. Our office sends out a communication in advance of the 65th birthday to explain what action is required by the retiree or covered dependent. If you or your covered dependent become entitled to Medicare for other reasons than turning age 65, it is your responsibility to make sure that you and/or your covered dependent enrolls in Medicare Parts A and B upon entitlement and you must notify the Office of Human Resources.

Please attach the necessary required documentation and/or copy of your Medicare card before submitting your enrollment form. For more information about required documentation, click HERE. To upload your documents, click on the attachment (paperclip) symbol on the left or bottom of the page.

For more information about the health & life insurance plans, please visit the Office of Human Resources (OHR) Retiree Health Insurance Webpages.

All health insurance questions should be directed to OHR's MC311 Customer Service Center at 240-773-6471 (Mon-Fri 8 am - 5 pm) to open a service request.  A member of the health insurance team will respond to your service request in the order it is received.  TIP: Please provide an email address at the time you place your Service Request. This will ensure the fastest response possible.

After you submit your form, you will see a pop-up message that allows you to download a copy of your form. You are strongly encouraged to download the form to keep a copy for your records.

You will also receive an email that your form has been submitted. This email acts as confirmation that your form was successfully submitted.

Additionally, a printed confirmation statement will be mailed to your home address within 10-14 business days after you submit your completed form.

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By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
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Official state marriage certificate (certified by appropriate state or county official) Click Here to Upload
State birth certificate Click Here to Upload
Medicare ID card Click Here to Upload
Adoption or placement for adoption papers Click Here to Upload
Medical plan verification of disability prior to age 26 (For disabled dependent over 26) Click Here to Upload
Court order granting legal custody (legal guardianship) Click Here to Upload
Death certificate Click Here to Upload